Kcronin1122
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Hello,
I needing some input on coding this cath procedure. Please see note below.
I am billing
93531-26
93566
93567
36010-XU
36010-XU
36011
76937-26
Historical Background and Indications:
GEORGE is a 19 year old male with double outlet right
ventricle who underwent staged palliation with a DKS with shunt,
Glenn, and extracardiac fenestrated Fontan. He has a history of
coarctation s/p angioplasty and elevated Fontan pressures. He
presents for repeat evaluation and possible coarctation
angioplasty or stent placement.
Description of Procedure:
The procedure included a left and right heart catheterization
with oximetry, hemodynamics, and angiography.
GEORGE was brought to the cardiac catheterization lab. After all
consents were checked and the hold points completed, he was
placed in the usual position and was placed under general
anethesia by the anesthesia team. The access site was prepared in
the usual sterile manner. Vascular ultrasound imaging was
utilized to define selected vessel patency. Real-time imaging
was used during vascular access attempts, including visualization
of needle passage into the vessel lumen, due to need minimize
vascular complications. Ultrasound imaging was captured and
placed in the medical record. Access was obtained using the
Seldinger technique in the right femoral vein with a 8 French
sheath and the right femoral artery with a 5 French sheath. After
access was obtained and sheaths were placed, a 7 French wedge
catheter and a 5F pigtail catheter were utilized to perform
hemodynamic measurements. Hemodynamics were notable for an
elevated pulmonary vascular resistance at 3.2 iWU. Therefore he
was placed on 70% FiO2 and after 10 minutes repeat hemodynamics
were obtained and his PVR dropped to 1.9 iWU.
We then proceeded with angiography. The Wedge was used to
perform an angiogram in the innominate vein. The wedge was
removed and a 7F Berman was used to perform angiogram in the
superior and inferior vena cava. The Berman was removed and the
5F pigtail was used to perform angiography in the right
ventricle, aorta, and proximal descending aorta. There was a
mild angiographic narrowing in the proximal descending aorta but
there was no significant gradient. This concluded the case.
After completion of the procedure, local anesthesia was given at
the access site. The sheaths were removed and hemostasis was
obtained. Lamont was extubated and transferred to the PACU in
stable condition. The estimated blood loss was 5 mL. The total
fluoroscopy was DAP 116.77 Gycm2 and Air Kerma 760.41 mgy. 158 ml
of contrast were given in total. A total of 5000 units of IV
heparin were given throughout the case.
There were no complications.
Catheterization Findings:
Qp = 2.68 L/min (1.40 L/min/m²)
Qs = 3.27 L/min (1.70 L/min/m²)
Rp = 1.68 units (3.22 units x m²)
Rs =
Qp/Qs = 0.82 : 1 | Rp/Rs =
Heart Rate: 55 bpm
VO2: 105 ml/min/m²
Hemoglobin: 17.0 gm/dL
Inspired O2: 21%
pH: 7.37
pCO2: 39.9
pO2: 70.0
HCO3: 22.9
Qp = 4.06 L/min (2.11 L/min/m²)
Qs = 4.91 L/min (2.56 L/min/m²)
Rp = 0.99 units (1.89 units x m²)
Qp/Qs = 0.83 : 1
Heart Rate: 55 bpm
VO2: 130 ml/min/m²
Hemoglobin: 17.0 gm/dL
Inspired O2: 70%
pH: 7.33
pCO2: 44.5
pO2: 89.6
HCO3: 23.2
Angiography
1. Innominate vein (7F Wedge, AP/Lat projections): There is an
unobstructed innominate vein to the superior vena cava. There is
a small venous collateral which is occluded by a previously
placed device.
2. Superior vena cava/Glenn (7F Berman, LAO/Lat projections):
There is an unobstructed Glenn and branch pulmonary arteries with
normal arborization. There is normal pulmonary venous return
during the levophase.
3. Inferior vena cava/Fontan (7F Berman, AP/Lat projections):
There is an unobstructed Fontan conduit to the branch pulmonary
arteries. The fenestration is patent with a mild plus right to
left angiographic shunt. Slightly more flow to the right
pulmonary artery than the left.
4. Right ventricle (5F Pigtail, LAO/Lat projections): There is
ectopy induced TR with a dilated right ventricle with normal RV
systolic function. The is mild sub aortic stenosis and an
unobstructed neo-aortic outflow.
5. Aortic root and proximal descending aorta (5F Pigtail,
LAO/Lat projections): There is mild to moderate native aortic
insufficiency which may be catheter induced and no significant
neo-aortic insufficiency. There is a left aortic arch with
normal branching of the head and neck vessels. There is a mild
narrowing of the aortic isthmus.
Impression:
GEORGE is a 19 year old male with
1. Double outlet right ventricle with hypoplastic left ventricle
including Damus-Kaye-Stansel/Norwood and totalcavopulmonary
anastomosis with 6-mm fenestration.
A. Status post balloon dilatation of coarctation
2. Mildly elevated RVEDP (11 mmHg)
3. Elevated PA pressure (17 mmHg) elevate PVR (3.2 iWU)
A. Responsive with 70% FiO2 with normal PVR (1.9 iWU)
4. Fenestration patent
5. Unobstructed Glenn, Fontan, and branch pulmonary arteries
6. Mild angiographic narrowing of proximal descending aorta with
no significant gradient (4 mmHg)
I needing some input on coding this cath procedure. Please see note below.
I am billing
93531-26
93566
93567
36010-XU
36010-XU
36011
76937-26
Historical Background and Indications:
GEORGE is a 19 year old male with double outlet right
ventricle who underwent staged palliation with a DKS with shunt,
Glenn, and extracardiac fenestrated Fontan. He has a history of
coarctation s/p angioplasty and elevated Fontan pressures. He
presents for repeat evaluation and possible coarctation
angioplasty or stent placement.
Description of Procedure:
The procedure included a left and right heart catheterization
with oximetry, hemodynamics, and angiography.
GEORGE was brought to the cardiac catheterization lab. After all
consents were checked and the hold points completed, he was
placed in the usual position and was placed under general
anethesia by the anesthesia team. The access site was prepared in
the usual sterile manner. Vascular ultrasound imaging was
utilized to define selected vessel patency. Real-time imaging
was used during vascular access attempts, including visualization
of needle passage into the vessel lumen, due to need minimize
vascular complications. Ultrasound imaging was captured and
placed in the medical record. Access was obtained using the
Seldinger technique in the right femoral vein with a 8 French
sheath and the right femoral artery with a 5 French sheath. After
access was obtained and sheaths were placed, a 7 French wedge
catheter and a 5F pigtail catheter were utilized to perform
hemodynamic measurements. Hemodynamics were notable for an
elevated pulmonary vascular resistance at 3.2 iWU. Therefore he
was placed on 70% FiO2 and after 10 minutes repeat hemodynamics
were obtained and his PVR dropped to 1.9 iWU.
We then proceeded with angiography. The Wedge was used to
perform an angiogram in the innominate vein. The wedge was
removed and a 7F Berman was used to perform angiogram in the
superior and inferior vena cava. The Berman was removed and the
5F pigtail was used to perform angiography in the right
ventricle, aorta, and proximal descending aorta. There was a
mild angiographic narrowing in the proximal descending aorta but
there was no significant gradient. This concluded the case.
After completion of the procedure, local anesthesia was given at
the access site. The sheaths were removed and hemostasis was
obtained. Lamont was extubated and transferred to the PACU in
stable condition. The estimated blood loss was 5 mL. The total
fluoroscopy was DAP 116.77 Gycm2 and Air Kerma 760.41 mgy. 158 ml
of contrast were given in total. A total of 5000 units of IV
heparin were given throughout the case.
There were no complications.
Catheterization Findings:
Qp = 2.68 L/min (1.40 L/min/m²)
Qs = 3.27 L/min (1.70 L/min/m²)
Rp = 1.68 units (3.22 units x m²)
Rs =
Qp/Qs = 0.82 : 1 | Rp/Rs =
Heart Rate: 55 bpm
VO2: 105 ml/min/m²
Hemoglobin: 17.0 gm/dL
Inspired O2: 21%
pH: 7.37
pCO2: 39.9
pO2: 70.0
HCO3: 22.9
Qp = 4.06 L/min (2.11 L/min/m²)
Qs = 4.91 L/min (2.56 L/min/m²)
Rp = 0.99 units (1.89 units x m²)
Qp/Qs = 0.83 : 1
Heart Rate: 55 bpm
VO2: 130 ml/min/m²
Hemoglobin: 17.0 gm/dL
Inspired O2: 70%
pH: 7.33
pCO2: 44.5
pO2: 89.6
HCO3: 23.2
Angiography
1. Innominate vein (7F Wedge, AP/Lat projections): There is an
unobstructed innominate vein to the superior vena cava. There is
a small venous collateral which is occluded by a previously
placed device.
2. Superior vena cava/Glenn (7F Berman, LAO/Lat projections):
There is an unobstructed Glenn and branch pulmonary arteries with
normal arborization. There is normal pulmonary venous return
during the levophase.
3. Inferior vena cava/Fontan (7F Berman, AP/Lat projections):
There is an unobstructed Fontan conduit to the branch pulmonary
arteries. The fenestration is patent with a mild plus right to
left angiographic shunt. Slightly more flow to the right
pulmonary artery than the left.
4. Right ventricle (5F Pigtail, LAO/Lat projections): There is
ectopy induced TR with a dilated right ventricle with normal RV
systolic function. The is mild sub aortic stenosis and an
unobstructed neo-aortic outflow.
5. Aortic root and proximal descending aorta (5F Pigtail,
LAO/Lat projections): There is mild to moderate native aortic
insufficiency which may be catheter induced and no significant
neo-aortic insufficiency. There is a left aortic arch with
normal branching of the head and neck vessels. There is a mild
narrowing of the aortic isthmus.
Impression:
GEORGE is a 19 year old male with
1. Double outlet right ventricle with hypoplastic left ventricle
including Damus-Kaye-Stansel/Norwood and totalcavopulmonary
anastomosis with 6-mm fenestration.
A. Status post balloon dilatation of coarctation
2. Mildly elevated RVEDP (11 mmHg)
3. Elevated PA pressure (17 mmHg) elevate PVR (3.2 iWU)
A. Responsive with 70% FiO2 with normal PVR (1.9 iWU)
4. Fenestration patent
5. Unobstructed Glenn, Fontan, and branch pulmonary arteries
6. Mild angiographic narrowing of proximal descending aorta with
no significant gradient (4 mmHg)